Case ReportJ Gastric Cancer 2016;16(1):54-57 http://dx.doi.org/10.5230/jgc.2016.16.1.54

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Introduction

Gastrointestinal intussusception in adults is a rare condi-

tion and represents only 5% of all intussusceptions.1 Ileo-ileal

and colo-colic intussusceptions are the most common types of

gastrointestinal intussusceptions in adults. Gastroduodenal intus-

susceptions are rare, and frequently result from the prolapse of an

underlying pedunculated gastric wall lesion into the duodenum.

Various pathologies like adenoma, leiomyoma, lipoma, hamar-

toma inflammatory fibroid polyp, adenocarcinoma, and leio-

myosarcoma can cause this pathology.2-4 Gastrointestinal stromal

tumors (GISTs) comprise only 1% to 3% of all gastrointestinal

tract tumors, with 60% of them arising in the stomach. They are

reported to cause gastric gastrointestinal intussusceptions infre-

quently.5,6 In this report, we aimed to present radiologic and clini-

cal findings of a unique case with gastroduodenal intussusception

induced by an underlying gastric GIST and complicated with

acute pancreatitis.

Case Report

An 85-year-old woman complaining of abdominal and

epigastric discomfort, nausea, and weight loss during the last

6 months was referred to a gastrointestinal clinic for further

evaluation. Her body mass index was 27 kg/m2. Laboratory

tests including complete blood count and biochemistry panel

were within the normal range. A 6 by 5 cm epigastric mass was

found by abdominal ultrasonography using an Aplio XG scan-

ner equipped with a 5-MHz convex transducer (Toshiba Medical

Systems, Tokyo, Japan). An intravenous (IV) contrast-enhanced

computed tomography (CT) demonstrated a diffusely enhancing

luminal mass at the gastric fundus (Fig. 1). There was no sign of

extraluminal invasion or metastasis. The patient did not provide

consent for gastric endoscopy and was discharged from the hos-

pital upon her demand. One month after the initial presentation,

the patient presented at the emergency department with severe

acute abdominal pain radiating to the back, accompanied with

pISSN : 2093-582X, eISSN : 2093-5641

Correspondence to: Mehmet Siddik Yildiz

Department of Radiology, Dunya Hospital, Çamlıtepe Mah. TPAO Bulvarı No:265, 72070 Batman, TurkeyTel: +90-5070362230, Fax: +90-488-221-18-88E-mail: dr.msyx@hotmail.comReceived January 7, 2016Revised February 27, 2016Accepted February 28, 2016

Acute Pancreatitis and Gastroduodenal Intussusception Induced by an Underlying Gastric Gastrointestinal Stromal

Tumor: A Case Report

Mehmet Siddik Yildiz, Ahmet Doğan1, Ibrahim Halil Koparan, and Mehmet Emin Adin2

Departments of Radiology and 1General Surgery, Dunya Hospital, Batman, 2Department of Radiology, Silvan Dr. Yusuf Azizoğlu Hospital, Diyarbakır, Turkey

Gastrointestinal stromal tumors (GISTs) are rare tumors of the gastrointestinal system and comprise only 1% to 3% of all gastrointestinal tract tumors, with the majority of them arising in the stomach. In this report, we present the unique findings of a case of gastroduodenal intussusception caused by an underlying gastric GIST and complicated with severe acute pancreatitis.

Key Words: Gastrointestinal stromal tumors; Pancreatitis, acute necrotizing; Stomach; Intussusception

Invagination and Pancreatitis in Gastric GIST

55

nausea and vomiting. Laboratory findings were suggestive of an

acute inflammatory response (white blood cell 21.66×109/L, C-

reactive protein 0.9 mg/L, serum albumin 2.6 g/dl, serum glucose

185 mg/dl, and serum chlorine 110 mmol/L). Amylase and lipase

values were elevated (1,974 IU/L and 1,503 IU/L, respectively),

whereas liver enzymes and bilirubin values were within the nor-

mal range. A control IV contrast-enhanced CT study showed a

gastric mass protruding toward the duodenum and obliterating

the gastric exit and duodenal lumen. Gastric wall thickening and

gastroduodenal intussusception were evident. The common biliary

duct was compressed by the mass and resulted in dilation of the

proximal biliary system. Pancreatic swelling, edema, and irregular

peripancreatic mesenteric fat stranding were suggestive of acute

pancreatitis (Fig. 2). Abdominal laparotomy revealed gastroduo-

denal intussusception due to a gastric mass arising from the supe-

rior part of the corpus. The obstruction of the ampulla vateri and

A B C

D E

Fig. 2. (A) Gastroduedonal intussusception. (B, C) The mass protruding to the duedonum and causing obstruction (arrows). Also visible are stranding of the peripancreatic fat and fluid accumulation around heterogenously ehancing pancreas, a sign of early necrosis. (D) Macroscopic view of the mass arising from gastric corpus (arrow). (E) Perioperative view of pancreas. Please note relatively dark portion of the pankreas correspond-ing to pancreatic necrosis.

A B

Fig. 1. Heterogenously enhancing en-doluminal mass (arrows) arising from gastric fundus is seen on axial (A) and coronal (B) computed tomography images obtained after intravenous contrast administration at initial ad-mission of the patient.

Yildiz MS, et al.

56

consequent edema and necrosis in the pancreas were also visible

during surgery after exploration of the retrocolic region. Because

of the location, size, and extent of the mass, wedge resection was

opted out as a surgical option. The patient underwent subtotal

gastrectomy and Roux and Y anastomosis (Fig. 2). Histopatho-

logic evaluation of the tumor specimen was most compatible with

benign gastric GIST demonstrating proliferation of spindle cells

with long oval nuclei.

Discussion

In this report, we present the findings of a case of gastro-

duodenal intussusception caused by an underlying gastric GIST

complicated with acute pancreatitis. According to our literature

review, this is the first reported case of gastric GIST present-

ing with gastroduodenal intussusception accompanied with acute

pancreatitis.

GISTs are rare tumors of the gastrointestinal system and ac-

count for 5% to 6% of all sarcomas. They comprise only 1% to

3% of all gastrointestinal tract tumors, with 60% of them arising

in the stomach.6 The usual symptom is abdominal discomfort,

but they may cause gastrointestinal obstruction in 10% to 30% of

cases. Bleeding of the GISTs may present clinically with melena,

hematemesis, or iron deficiency anemia.7 Abdominal pain usu-

ally occurs around the epigastric region, and has a sudden onset

and intermittent character with possible accompanying vomiting.

GISTs may be detected with gastric endoscopy as an endophytic

mass with a smooth bright surface. Endoscopic ultrasound may

be helpful in further evaluation of the mass, particularly in as-

sessing the level of gastric wall involvement. Contrast-enhanced

CT scan is currently the imaging modality of choice. Unlike

endoscopy, it provides details beyond the gastric lumen and is

critical in preoperative assessment. Magnetic resonance imaging is

also helpful in the assessment of large exophytic masses. Surgical

excision is the treatment of choice if the tumor is determined to

be resectable. Care must be taken during resection as most gastric

GISTs have a pseudocapsule formation and rupture may result in

tumor spillage.8

Gastroduodenal intussusception induced by gastric GISTs is a

very rare cause of gastroduodenal obstruction.9 Surgery may be

needed for definitive diagnosis.10 Another rare complication of

gastric GISTs is acute pancreatitis caused by duodenal obstruc-

tion. A few studies have also reported acute pancreatitis induced

by a gastric hyperplastic polyp prolapsing into the duodenum.11,12

In most reports of gastric mass-induced acute pancreatitis, the

masses tended to arise in the distal part of stomach, mainly the

antrum.11 According to our review, there are three case reports

in the English literature presenting acute pancreatitis secondary

to prolapsed gastric GISTs.13-15 In one of these cases, the mass

originated from the gastric antrum, whereas the masses originated

from the gastric fundus in the other two cases. In all three cases,

the masses were prolapsed into the duodenum and induced acute

pancreatitis. No intussusception was reported in all three cases.

In conclusion, we report the unique case of acute pancreatitis

induced by gastroduodenal intussusception in a patient with a

previously known gastric GIST arising from the corpus and caus-

ing duodenal obstruction.

The study was retrospective and complied with ethical stan-

dards for retrospective research. No human or animal subjects

were involved. Informed consent was provided for publication of

the case reported here.

Conflicts of Interest

No potential conflict of interest relevant to this article was re-

ported.

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